The Goofy Line and Its Economics Explained

I placed a central line (a big IV) into the subclavian vein (under your collar bone). It's used in critically ill patients with poor IV access to give medications very quickly and to help guide therapies. Here's a graphical representation of what it's supposed to look like:

Now. Check out this chest x-ray. It's that line looking thingy on the left side of the picture. Notice how it loops up on itself. (click image to enlarge) I've never had that happen. Nor do I know why it happened. Stenosis perhaps? Another first for Happy. To fix it, you can withdraw and re advance blindly, or have a radiologist manipulate it under a fluoroscope (image to the right). Now, let me give you a little lesson on how much I get paid for putting this special little line in. It takes, on average, about 15-20 minutes to consent the patient, dress, prep and suture the line. 15-20 minutes from start to finish. How much does Medicare pay me for my efforts? I refer you to my explanation of RVU (relative value units). In this post I explain the formula for how physicians get paid:
To calculate the payment for every physician service, the components of the fee schedule (physician work, practice expense, and malpractice RVUs) are adjusted by a geographic practice cost index (GPCI). Payments are converted to dollar amounts through the application of the conversion factor which is updated annually(this is what the SGR or sustainable growth rate affects). The general formula for calculating the fee schedule amount is: Payment = [(RVU work x GPCI work) + (RVU Practice expense x GPCI Practice expense) + (RVU malpractice x GPCI malpractice) x Conversion Factor. The conversion factor for 2007 is $37.8975; the same as in 2006.

In the purest sense for creating relative values, you strip out the malpractice component and you strip out the physician expense component and you get the actual value that Medicare, through the RUC, applies to all physician encounters. The physician work RVU value. Trying to make an apples to apples comparison across every possible specialty and encouter possible. Trying to set a relative value for a total knee replacement, as it compares to a mid level office visit by your comprehensive care doctor. It is this weight that is critically flawed. A system that is destroying the access and flow of comprehensive care in this country. How do I know that? Because the numbers don't lie. Let me walk you through the example of my central line and it's relative value (RVU) as it compares to my hospital follow up cognitive encounters, which make up 50% of my billing.

Medicare, through the RUC, a committee strongly controlled by specialists( who do procedures), rubber stamps their recommendations for payment of all encounters a physician has with a patient. Every encounter has a CPT code, which the AMA also owns.

So here's how it works. I show up to do a central line. the AMA CPT code is 36556. I mark this code on my billing sheet and turn it into my billing company. So how much do I get paid? The RUC has determined that the physician component for a 36556 is worth 2.5 RVUs. Now remember, this takes me about 15-20 minutes to do. Currently, one RVU is worth about $38 as determined by law. So, do the math. 2.5 RVUs is worth $95. This is a pure payment of physician effort. It strips out malpractice and expense to the physician for supplies, nursing, syringes sterile equipment. For 15-20 minutes of work, that works out to $285-$380/ hour. That's what the RUC believes the physician expertise and training and knowledge is worth for putting these things in. How does this compare with my cognitive hospital follow up encounters?

A level one hospital follow up visit, CPT code 99231 is assigned a physician work component RVU value of 0.76 RVUs. The AMA, in their definition of this CPT code, states this encounter should take 15 minutes. That works out to $29 (0.76 *$38) for 15 minutes of work. That's what the RUC believes this encounter is worth, purely from a physician effort, experience and training. That works out to $116 an hour.

A level two hospital follow up visit, CPT code 99232 is assigned a physician work component RVU value of 1.39 RVUs. The AMA, in their definition of this CPT code states this encounter should take 25 minutes. That works out to $53 (1.39*$38) for 25 minutes of work. That's what the RUC believes this encounter is worth, purely from a physician effort, experience and training. That works out to $127/hour

A level three hospital follow up visit, CPT code 99233 is assigned a physician work component RVU value of 2.0 RVUs. The AMA, in their definition of this CPT code states this encounter should take 35 minutes. That works out to $76 (2.0*$38) for 35 minutes of work. That's what the RUC believes this encounter is worth, purely from a physician effort, experience and training. That works out to $130/hour.

Do you see the problem here? I have placed hundreds of central lines. Most specialists never place a central line. Gastroenterologists, orthopaedic surgeons, dermatologists, even most cardiologists do not place central lines. Yet many hospitalists do. Many critical care specialists do. Many community family practice docs do. The issue has nothing to do with the length of training. Which brings me back to the original point. If it's not related to length of training and expertise, why is it worth 2-3 times more in assigned value to the physician effort than are my hospital follow up cognitive encounters.

That's the question nobody can answer for me. And that's why every medical student is going into specialties that are high in procedural volume. Because that's where the money is. It's not a mystery. It's built into the irrational system. And it is bankrupting American health care as we know it.